CMS Initiates New Evaluation Criteria for Medicare Advantage Plans to Enhance Star Rating System

CMS Proposes Major Overhaul of Medicare advantage Star Ratings

Washington D.C. – The Centers for Medicare & Medicaid Services (CMS) unveiled a proposed rule Tuesday that would significantly reshape the Medicare Advantage (MA) star ratings system. The agency aims to streamline quality measurements,refocus on core clinical care,and simplify the program for beneficiaries.

The proposed changes include eliminating 12 existing quality measures largely focused on administrative processes – areas where health plan performance is consistently high and difficult for beneficiaries to differentiate. These cuts,slated to take effect in the 2029 star ratings,encompass metrics like customer service responsiveness,appeal timeliness,and accessibility features at call centers.

CMS also intends to not implement the “Excellent Health Outcomes for All” reward, designed to incentivize improved care for low-income, disabled, or dual-eligible enrollees. However,the agency is proposing the addition of a new quality measure focused on depression screening and follow-up care.

Why This Matters:

The star ratings are critical for both beneficiaries and insurers. They help individuals evaluate the quality of MA and Part D plans before enrollment. More importantly, these ratings directly impact insurer finances, with higher star ratings unlocking lucrative bonus payments and a competitive edge within the rapidly growing Medicare Advantage program.

Recent years have seen fluctuating star ratings – largely flat for 2026 after a period of decline – while MA plans face increasing financial pressures, leading some insurers to exit markets and reduce benefits.

According to CMS

How will the increased weighting of consumer experience measures impact MAO strategies for improving Star Ratings?

Understanding the Shift in Medicare Advantage Star Ratings

The Centers for Medicare & Medicaid Services (CMS) is implementing significant changes to the evaluation criteria used for the Medicare Advantage (MA) Star Rating system, effective for plans in 2026. These updates aim to more accurately reflect the beneficiary experience and drive improvements in healthcare quality within the MA program.This impacts Medicare Advantage plans, MA ratings, and ultimately, Medicare beneficiaries. The changes are substantial and require careful attention from health plans, providers, and anyone involved in the Medicare system.

Key Changes to the star Rating Methodology

CMS is focusing on several key areas with these new criteria. Here’s a breakdown of the most impactful adjustments:

* Increased Weighting of Consumer Experience Measures: CMS is substantially increasing the weight given to measures directly reflecting patient experience. This includes:

* Care Coordination: Measures assessing how well plans coordinate care for members with chronic conditions.

* Member Complaints: A greater emphasis on the volume and resolution of member grievances.

* Health Outcomes: Expanding the use of health outcomes data, notably for chronic conditions like diabetes and heart failure.

* Digital Experience: New measures evaluating the usability and accessibility of plan websites and mobile apps.This reflects the growing importance of telehealth and digital health in Medicare.

* Expanded Use of Health Equity Measures: CMS is introducing new measures designed to assess and address health disparities. This includes stratifying performance data by race,ethnicity,language,and socioeconomic status. This focus on health equity is a major priority for CMS.

* Refined Measures for Special Needs Plans (SNPs): SNPs will face more targeted evaluation criteria aligned with the specific needs of their enrolled populations (e.g., dual-eligible beneficiaries, those with chronic conditions). This ensures SNP performance is accurately assessed.

* New Measures Related to Behavioral Health: Recognizing the critical importance of mental health, CMS is adding measures related to access to and quality of behavioral healthcare services. This includes assessing mental health coverage and substance use disorder treatment.

* Data Validation and accuracy: CMS is strengthening data validation processes to ensure the accuracy and reliability of the data used in the Star Rating calculations. This is crucial for maintaining the integrity of the Star Rating system.

Impact on Medicare Advantage Organizations (MAOs)

These changes necessitate a proactive approach from maos. Here’s what plans need to do:

1. Data infrastructure Investment: Invest in robust data collection and analysis systems to accurately track and report on the new measures.
2. Care Model Redesign: Re-evaluate and potentially redesign care models to improve performance on consumer experience and health outcomes measures.
3. Provider Engagement: Collaborate closely with providers to ensure they understand the new requirements and are aligned with the plan’s quality enhancement goals.
4. Health Equity Initiatives: Implement targeted initiatives to address health disparities and improve outcomes for underserved populations.
5. Digital Health Strategy: Enhance digital health offerings to improve member engagement and access to care.
6. Compliance and Reporting: Ensure full compliance with CMS reporting requirements and data validation processes.

Benefits of a Higher Star Rating

Achieving a higher Star Rating offers significant advantages for MAOs:

* Increased Enrollment: Higher-rated plans are more attractive to beneficiaries and tend to experience higher enrollment growth.

* Quality Bonus Payments: CMS provides financial incentives to plans with high Star Ratings. These quality bonus payments can be substantial.

* Marketing Advantages: plans with 4 or more stars have greater marketing adaptability.

* Enhanced Reputation: A high Star Rating enhances a plan’s reputation and builds trust with beneficiaries.

* Competitive Advantage: In a competitive market, a strong Star Rating can differentiate a plan from its competitors.

Practical Tips for Improving star Ratings

* Focus on Patient-Reported Outcomes (PROs): Actively collect and analyze PROs to understand the beneficiary experience.

* Implement a Thorough Grievance and Appeals Process: Ensure timely and effective resolution of member complaints.

* Proactively manage Chronic Conditions: Implement evidence-based care management programs for members with chronic conditions.

* Expand Access to Telehealth: Offer convenient and accessible telehealth options.

* Invest in Data Analytics: utilize data analytics to identify areas for improvement and track progress.

* Regularly monitor CMS Guidance: Stay up-to-date on the latest CMS guidance and regulations.

Real-World Example: A Leading SNP’s Approach

A leading SNP in california proactively addressed the new CMS requirements by implementing a culturally tailored care coordination program for its dual-eligible members. This program included bilingual care managers,transportation assistance,and assistance with navigating the healthcare system. As a result, the SNP saw significant improvements in its Star rating, particularly in measures related to care coordination and member satisfaction. This demonstrates the power of targeted interventions to improve SNP ratings.

Resources for Further Information

* CMS Medicare Advantage Star Ratings Website: https://www.cms.gov/Medicare/Star-Ratings

* CMS Annual Call Letter: Provides detailed guidance on the annual MA and Part